Dracunculiasis is a parasitic infection caused by a filarial
worm (Dracunculus medinensis {i.e., Guinea worm}) that is
transmitted through contaminated drinking water. Approximately 1
year after a person is infected, one or more meter-long adult
female worms begin to emerge through the skin, often incapacitating
the patient for greater than or equal to 2 months. Despite a
dramatic decrease in cases worldwide, dracunculiasis is still
occasionally imported into the United States. Since 1995, two cases
of dracunculiasis have been reported in the United States, both
imported from Sudan. This report summarizes the investigation of
these cases.

Patient 1. A 9-year-old girl residing in Tennessee had
emigrated from Sudan in September 1995 (1). Before the girl left
Sudan, a Guinea worm had emerged and had been extracted from her
right lower leg. The lesion had healed when she arrived in the
United States. After she had been in the United States for 3 weeks,
another Guinea worm began to emerge from her left leg. Medical
examination at a local health clinic revealed a string-like worm
dangling from a lesion on her left leg, and she was referred to an
infectious disease specialist. The leg was secondarily infected and
swollen, and the girl was unable to walk. Despite antibiotic
treatment, her cellulitis did not improve, and the lesion was
surgically opened, drained, and debrided of pus, necrotic debris,
and fragments of the Guinea worm. The patient was hospitalized for
2 weeks, requiring surgery to stretch a contracture of her ankle
and to apply a skin graft to the wound. After outpatient physical
therapy, she was able to walk without crutches.

Patient 2. A 31-year-old woman residing in Connecticut had
emigrated from Sudan in January 1997. In April 1997, she was
evaluated at a university clinic for possible tuberculosis (TB). A
radiograph revealed lung lesions consistent with TB and a worm-like
calcification in her left chest. Physical examination revealed
multiple, indurated, oval lesions 4-8 cm in diameter on both lower
legs. The patient reported the lesions had been present for 1 year
and were intermittently painful. She recalled that a long
string-like worm had emerged from her leg during the previous year.
Biopsy of the leg lesions revealed erythema induratum, consistent
with Bazin disease, a cutaneous manifestation of TB. The patient
had evidence of a dead and calcified Guinea worm in her chest and
a history suggesting a live Guinea worm had emerged from her leg
before she arrived in the United States. She also had pulmonary TB
with a cutaneous tuberculid skin manifestation. Treatment with
isoniazid, rifampin, and pyrazinomide resulted in elimination of
acid-fast bacilli from sputum and resolution of cutaneous
manifestations.

Editorial Note

Editorial Note: No case of dracunculiasis transmitted in the United
States has ever been reported, and importations of dracunculiasis
to the United States are infrequent. Although both cases in this
report involved refugees from Sudan, they differ in clinical
manifestations and epidemiologic significance.

The risk for transmission of dracunculiasis from active cases
imported to the United States is low; transmission would require a
person with an emerging worm to enter a stagnant, freshwater pond
containing copepods, and persons to drink directly from the source
greater than or equal to 1 week after contamination. The disease
can be completely prevented by keeping infected persons from
entering and contaminating the water supply or by providing
drinking water free of Dracunculus larvae. Humans are the only
vertebrate host for D. medinensis. Only the worm that emerged from
patient 1 could have posed any risk for contaminating a source of
water in the United States. The calcified worm and the history of
an emerging worm in patient 2 reflected previous infections without
any possibility of transmission in the United States.

Although no drug aborts dracunculiasis infection or hastens
expulsion of the adult worm, compounds that reduce inflammation and
antibiotics to treat secondary infection facilitate extraction.
Dracunculiasis treatment has included cleaning of the lesion and
gentle traction to draw the long worm through the skin; the process
may take several weeks. Care must be taken to avoid breaking the
worm under the skin and subsequent allergic reaction to the
internal components of the worm. Physicians who treat patients who
have imported dracunculiasis can obtain treatment advice from CDC.

The global campaign to eradicate dracunculiasis began in 1986;
the number of cases worldwide decreased by greater than 95% (from
approximately 3.2 million cases in 1986 to 152,805 in 1996).
Ongoing transmission of dracunculiasis is limited to 16 countries
in Africa (2). In Asia, the disease is still occurring in Yemen. In
India, the only other Asian country not yet declared free of
dracunculiasis, no cases have been reported since July 1996.
Pakistan, which reported its last case in October 1993, was
certified free of dracunculiasis by the World Health Organization
in 1997 (3).

In comparison with the dramatic decrease in cases and in
villages with endemic disease globally, the numbers of reported
cases and villages with endemic disease in Sudan increased sharply
from 1993 to 1996. The areas with the highest prevalence of
dracunculiasis are in southern Sudan, where war hampered
surveillance for cases and interventions. In 1996, the 64,608 cases
reported from areas in Sudan where surveillance was possible
accounted for 78% of all cases worldwide (4).

The detection and investigation of every active case brought
to the United States enables identification of places where
dracunculiasis may still be present and prevents establishment of
a focus of transmission in the United States. CDC requests that
medical practitioners report any cases of dracunculiasis in the
United States since 1990. A brief description of the case,
including where the patient may have acquired dracunculiasis,
location of treatment, approximate date of worm emergence, and
clinical outcome should be reported to Guinea Worm Cases, Division
of Parasitic Diseases, National Center for Infectious Diseases,
CDC, Atlanta, GA 30333; telephone (770) 488-4531; or by e-mail:
kdk1@cdc.gov.

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